Utilization Management Nurse Consultant – CST Zone

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate services for medical necessity and appropriate benefit utilization.

• Facilitate effective discharge planning processes.

• Collaborate with providers and facilities to assist members with complex needs.

• Assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.

• Gather and analyze clinical information.

• Utilize clinical criteria, guidelines, policies, and professional judgment to make coverage decisions.

• Communicate with providers and external partners to ensure coordinated care and treatment plans.

• Identify opportunities for referrals to additional programs, services, or care solutions.

• Promote quality care delivery and efficient benefit utilization.

• Act as a resource for internal and external stakeholders regarding utilization management processes and clinical considerations.

• Coordinate, document, and communicate all aspects of the utilization and benefit management process.

• Ensure that members receive appropriate care while complying with state and federal requirements and turnaround times.

⛳️ Requirements

• Current, unrestricted RN license.

• At least 2 years of clinical experience in an acute hospital setting (strong preference for medical-surgical, ICU, behavioral health, or other specialty areas).

• Strong clinical assessment and decision-making skills.

• Excellent organizational abilities with the capacity to manage multiple priorities.

• Capability to work independently and communicate effectively over the phone.

• Comfort with computer-based tasks, multitasking across multiple screens, and documenting while on calls.

• Preferred: at least 1 year of Utilization Review experience.

• Preferred: at least 1 year of Managed Care experience.

• Proficient in Microsoft Office (Word, Excel, PowerPoint, Outlook).

• Strong verbal communication skills over the phone.

• Proven ability to exercise sound judgment and collaborate with diverse teams.

• Associate Degree in Nursing (ADN) is required.

• Candidates must reside in a U.S. state within the CST Zone.

• Availability for Monday-Friday, 8:00 AM-5:00 PM CST.

• Required to work weekends (12 per year) and holidays (1 minor and 1 major per year).

• One shift from 1:00 PM-7:00 PM per month is required.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional well-being resources.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.